Known as voluntary deep inspiratory breath hold (DIBH), the
technique significantly reduces the radiation exposure the
heart receives during breast cancer treatments. Patients take
and hold a deep breath for up to 20 seconds, allowing their care team
to target the radiation exactly where it’s needed and avoid the cardiac
tissue.

“With this technique, we have a more effective and lower cost way to
spare the heart, and we get two things. We get separation of the heart
from the chest wall and we also get immobility, which we love in
radiation. We don’t want people moving. So it keeps our target still in
a patient-friendly way and it also moves the heart out of the way,”
said UVA radiation oncologist
Monica Morris, MD. “It’s very elegant.”

Avoiding Heart Damage
The potential damage to the heart caused by treatment of breast cancer
has been highlighted by a study recently published in the New
England Journal of Medicine. It found that radiation exposure to
the heart increased the rate of ischemic heart disease proportionate to
the exposure, beginning within weeks of treatment and continuing for at
least 20 years. Other papers have established a small increased risk of
heart disease and even death – a particular concern considering that
breast cancer is, in many cases, curable.

UVA’s technique has been demonstrated, in papers published in
peer-reviewed journals, to reduce the radiation exposure to the heart
significantly, even beyond the use of more expensive approaches, while
still producing outcomes as successful as the traditional treatment
approach. Other attempts at using breathing regulation to spare the
heart, such as active breathing control (ABC), require a mouthpiece
that forcibly controls breathing; with UVA’s technique, the patient is
in control.

“Patients really love it because they’re participating in their
treatment and care,” Morris said. Precise Treatment
UVA’s breathing technique combines advanced imaging with an active
role for the patient. Patients are given electronic goggles that show
them a virtual gauge tracking their breath holding. By watching the
visual feedback, patients can ensure they’re holding their breath
appropriately. “We have a software algorithm that verifies the accuracy
of the breath hold throughout the treatment time,” said UVA medical
physicist Krishni Wijesooriya, PhD. “It makes sure the patient always
stays in the same position when she’s being treated. If she moves out
of position, the radiation beam automatically turns off.”

The patient’s care team, meanwhile, uses advanced imaging to view
inside the body on not just one but two planes, creating a
three-dimensional depiction. This allows for an extremely precise
approach to administering the radiation, allowing the team to avoid
having the radiation beam pass through the heart.

“The imaging for positional accuracy, the procedure of voluntary deep
inspiratory breath hold and patient cooperation via visual bio feedback
– having them play a role – those three components together are what
make our program successful,” Wijesooriya said.

Better Cancer Care
The voluntary deep inspiratory breath hold technique was pioneered at
UVA by
Paul Read, MD, PhD, who also recently devised a streamlined
treatment for cancers that have spread to bone. Typically such
treatments span weeks, but Read’s approach reduces the treatment course
to a single day.

Morris and her UVA colleagues also offer condensed treatment courses
for early breast cancers, with options for treating both the whole
breast and partial breast.